1. Quality of life (Utility) Measurements In Relation to Health Economics
Prof. Dr. Jan J.V. Busschbach
Erasmus MC
Section Medical Psychology and Psychotherapy
Department of Psychiatry
NIHES Course
Quality of Life Measurement (HS11)

2. Slides: www.busschbach.com

3. Health Economics Comparing different allocations
Should we spent our money on
Wheel chairs
Screening for cancer
Comparing costs
Comparing outcome
Outcomes must be comparable
Make a generic outcome measure 3 3

4. Outcomes in health economics
Specific outcome are incompatible
Allow only for comparisons within the specific field
Clinical successes: successful operation, total cure
Clinical failures: “events”
“Hart failure” versus “second psychosis”
Generic outcome are compatible
Allow for comparisons between fields
Life years
Quality of life
Most generic outcome
Quality adjusted life year (QALY) 4 4

5. Quality Adjusted Life Years: QALYs
Example
Blindness
Time trade-off value is 0.5
Life span = 80 years
0.5 x 80 = 40 QALYs
0.00
1.00 X
0.5 x 80 = 40 QALYs
Life years 40 80 5 5

6. Area under the curve
Stel een persoon ontwikkelt een persoonlijkheidsstoornis. Bij zijn geboorte is ons voorbeeld nog naïef en gelukkig: een kwaliteit van leven vlak bij het optimum van 1. Maar dan wordt hij ouder, en in de pubertijd ontwikkelt zich een persoonlijkheidsstoornis en verliest hij kwaliteit van leven. Dit afglijden van de kwaliteit van leven bereikt een voorlopig dieptepunt rond zijn vijftigste. Na z’n 70e wordt het nog erger, want dan ontwikkeld hij ook allerhande lichamelijke klachten en op z’n 80e sterft hij.
Stel dat zo iemand een bewezen effectieve psychotherapie had gekregen rond zijn 25e levensjaar (KLIK). Als de therapie inderdaad werkzaam zou zijn, dan verbetert de kwaliteit van leven. Het blauwe gestreepte oppervlakte vertegenwoordigt dan de winst in termen van QALYs door de therapie. (KLIK) Het grijze valk wat overblijft vertegenwoordigd de restziekten.
Ik nam een patiënt met persoonlijkheidsstoornissen als voorbeeld, maar ik had hetzelfde grafiek kunnen tekenen voor een patiënt met diabetes. Bijvoorbeeld, de patiënt komt er op 25 jarige leeftijd achter dat hij diabeet is, en begint dan met insuline-injecties die de hem er weer redelijk bovenop helpen.
Als je twee heel verschillende ziektes in dezelfde grafiek kunnen weergeven (bijvoorbeeld persoonlijkheidsstoornissen en diabetes), dan kunnen we de ernst van die ziekten ook gemakkelijk met elkaar vergelijken. 6

7. Which health care program is the most cost-effective?
A new wheelchair for elderly (iBOT)
Special post natal care 7 7

8.
Dean Kamen
Segway
Jimi Heselden † 26 September 2010 8

9. Which health care program is the most cost-effective?
A new wheelchair for elderly (iBOT)
Increases quality of life = 0.1
10 years benefit
Extra costs: $ 3,000 per life year
QALY = Y x V(Q) = 10 x 0.1 = 1 QALY
Costs are 10 x $ 3,000 = $30,000
Cost/QALY = 30,000/QALY
Special post natal care
Quality of life = 0.8
35 year
Costs are $ 250,000
QALY = 35 x 0.8 = 28 QALY
Cost/QALY = 8,929/QALY 9 9

10. QALY league tables
Link to example sheet 10

11. Sackett et al.; Clinical Epidemiology

12. Introducing “Utilities”

13. QALY publications

14. Threshold NICE “As a guideline rule…,
…NICE accepts as cost effective those interventions with an incremental cost-effectiveness ratio of less than £20,000 per QALY …
…and that there should be increasingly strong reasons for accepting as cost effective interventions with an incremental cost-effectiveness ratio of over a threshold of £30,000 per QALY.”
Incorporating Health Economics in Guidelines and Assessing Resource Impact. The guideline Manual. NICE April 2008, Chapter 8, page 54

15. Modelling NICE decisions
At average levels for all covariates, a decision would have a 50% chance of rejection if its ICER were £45,118/QALY
Dakin, Devlin, Rice, Parkin, O’Neill, Feng (2013) The influence of cost effectveness and other factors on NICE decisions. (forthcoming)
We then used the regression equation to predict probability of rejection at different ICER values
Keeping all other variables at mean values
Plot rejection probability against ICER
This Basic model implies that a decision would have a 50% chance of rejection if its ICER were £45,118/QALY

16. Two points of critique QALYs are measured in a invalid way
Life years is not the problem, thus…
It must be the validity of quality of life assessment…
One should not use cost effectiveness
Often referred to as ‘ethics’ 16 16

17. Eric Nord: Egalitarian concernsB
0.0
1.0
Utility of Health A B 17 17

18. Burden as criteria
Pronk & Bonsel, Eur J Health Econom 2004, 5: 18 18

19. Costs/QALY as indicator of solidarity€ 80 € 60 €
Utility 40 20 A B C 19

20. Works with life years as well… it is not just QoL!€ 80 € 60 €
Live years 40 20 A B C 20

21. Costs/QALY versus Burden of diseaseX € € € € €
Samen met onder andere Prof Frans Rutten, Elly Stolk en Prof Werner Brouwer hebben we toen de volgende grafiek gemaakt. Op de verticale as (KLIK) staat de kostprijs per QALY (KLIK) die we overhebben voor verschillende interventies. Op de horizontale as (KLIK) staan ziektelast (KLIK), op een manier uitgedrukt ongeveer net zo als dat de World Health Organisation dat doet (KLIK). Beide getallen hebben we voor verschillende interventies uitgereken (KLIK) en we vonden de volgende punten (KLK).
Burden of disease 21

22. Dutch Council for Public Health and Health Care (RvZ, 2006)22 22

23. Burden / Costs effectiveness
NICE; Higer values end of life medication
The decisions to allow NHS use of trastuzumab (Herceptin) and imatinib (Glivec) pushed NICE’s cost effectiveness threshold above its notional £30 000 (€34 000; $46 000) per QALY. These decisions took place against a background of legal action by patients, attendant publicity, and political discomfort.
James Raftery, BMJ
CvZ: Pakketbeheer in de Praktijk 2
Bij de bepaling van de kosteneffectiviteit van een interventie hanteert het CVZ een bandbreedte van euro per QALY bij lage ziektelast tot euro per QALY bij hoge ziektelast.
J. Zwaap, CvZ

24. DALYs: Chris Murray WHO avoid QALY Havard Worked outside DALY
School of Public Health
Worked outside
Health economics
Med Decision Making
DALY
Person Trade-Off
Reinvented

25. Burden of disease: QALY lost = DALY (Disability adjusted life year)25

26. Burden of disease expressed as “QALY lost” = DALY
Disability adjusted life years
The inverse of QALY
Used by the WHO
Expresses burden of disease
Measure of priority
More burden, more investment
QALY lost (DALY) = Measure of solidarity 26

27. QALY: both for effectiveness and solidarity
Evaluations assess cost-effectiveness in term of cost/QALY
But many decisions can not be explained by cost/QALY
Explanation in terms of fairness
People disagree with distributional implications of QALY maximisation
Fairness is burden of disease
Burden of disease is QALY lost (DALY) 27 27

28. QALY debate

29. QALY debate Fairness is the issue in the QALY debate
QALY measurement is the straw man
Complex metric discussion
But same discussion applies with life years gained
Obviously QALYs must measured validly
That debate = rest of the course 29

30. 100 persons additionally 1 healthy year
Person Trade-Off
Values between patients
Not ‘within’ a patient like SG, TTO and VAS
Better equipped for QALY?
V(Q) = 1 - (A / B)
For instance:
V(Q) = 1 - (100/300)
V(Q) =
V(Q) = 0.67
?? persons 1 year
free from disease Q
100 persons additionally 1 healthy year

31. PTO gives extreme low values

32. PTO and it’s psychometrics
Paul Kind:
If we look at TTO and PTO...
we see that one of them is wrong
If we look at PTO alone...
We still see that one of them is wrong...
PTO is not a quick fix

33. Alternative applications
Link to out of pocket payments
Greater out of pocket payments for conditions with lower proportional shortfall
E.g. France and Belgium
For example:
No reimbursement for the mildest conditions, such as common cold, acute tonsillitis, acute bronchitis, onychomycosis, tinea pedis
Partial reimbursement for conditions mild to moderate conditions: Haemorrhoids, candidiasis, gastritis, osteoporosis, erectile dysfunction, acne conglobata
Etc.

34. Direct utility assessment
SG, TTO, PTO, VAS

35. Indirect utility assessment
HUI, EQ-5D, AQoL, 15D, Rosser index
MOBILITY
I have no problems in walking about
I have some problems in walking about
I am confined to bed
SELF-CARE
I have no problems with self-care
I have some problems washing or dressing myself
I am unable to wash or dress myself
USUAL ACTIVITIES (e.g. work, study, housework family or leisure activities)
I have no problems with performing my usual activities
I have some problems with performing my usual activities
I am unable to perform my usual activities
PAIN/DISCOMFORT
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort
ANXIETY/DEPRESSION
I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed